tu ^^^ IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I ■ 5 '""^^ l^'li^ = 1.8 1.25 U 1.6 ■» 6" ► ^ <^ /} ■c^ % s^ Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 l\ iV arative comfort and well-b/ing, with the complaints as above described. The skin showed signs of smallpo.x many years before. Tliero was .slight pallor of the mucous membranes; the scle- rotics were icteroid. There was no oedema or dyspnoea; the finger nails showed slight clul)bing; the inguinal glands were enlarged. There was a scar on the glans ])enis near the conmn. The right thigli showed the cicatrix of a surgical wound made for the treatment of the popliteal aneurism, already mentioned The lungs, nervous system, abdomen, and urine gave negative results on examination. The chief interest cefstred about the circulatory system. The arteries were slightly sclerosed. The jmlse was somewhat collapsing, of good tension, regular rhythm and volume. There was visible pulsation of the vessels of the neck: the carotids springing forward in systole. Palpation revealed a diffuse preeoidial pulsation with a prolonged diastolic thrill palpable on the right as far as the nipple line. The thrill was also pal|)able in the suprasternal notch, but its maximum intensity was about the third and fourth cartilages to the "eft of the sternum. The apex of the heart showed some displacment to the left, being located in the fifth inter- space one inch out«idt. the nipple. The transverso dulno^s encroached upon tlie left edge of tlie Hternu.n. 'Vhv sounds at th. apex were de- cidedly weaker than normal; at the ha^e one couhl not discover any ac- centuation of the second sound either pulmonary or aortic At thea,.ex a laiut diastolic murmur and a systolic murmur were audihle. in au- dition tx) these one could hear a musical murmur, diastolic m rhytnm, widely propagated over the chest, having its point of maxununi inten- sity, howe ' r, at the third left interspace. This murnmr was of rat high pitch ;nd was audihle to the patient. It couM ^e d.Btn c.l h' d'at a distance of from 18 to « . inches fron> the chest wall and o one occasion in a ,uiet roon. the murmur wa.s aud.ble at a distance fully five feet, the patient dressed and sitting .n a chair. 1 lie diagnos.s f aortic and mitral regurgitation was made. Various bFcu at.on . however, were made concerning the origin of the n.urniur just des r b The latient was discharged, ami for several months he pas e,l from und r our observation. He returned in May of 1898. A'-.t B.xteen months of pretty active life with freed,>m fron, distress had been en- Tyet'-t in April he becan.e very short of breath and h.s sleep w greatly disturbed by hideous dreams and attack, of dyspncBa^lc '.mplaints made on this occasion of admission to the hosjuUil di tt- with those at first noted. Precordial pain was the prom nent feature of the case at first; now he complained of sleeplessness an-l dyspnce>i, dyspncea even when at rest, and sometimes amoun ing to orth..pnoea llong with these allied complaints one found on exannmng the heart tliat the cardiac dulness had increased. The apex was now m the sixth space, the transverse dulness IJ to 2 mches greater. Ih le \Z epigas ric pulsation. A thrill was uncertain. The musical dia- tdic murmur Lard so widely was of a lower pitch yet retaunng it^ nuisical quality, but was no longer audil>le away fron. he chest wall. A • «to-and-fro" murmur was heard at the xiphoid cartilage. The patient wished to go home and was discharged on th« A^ "^ Jx,ne He remained in bed until October 6th, when he was finallj re- « fitted to the hospital, where he died on the 31^* of the same m^^^^^^^ The course of the case (luring the summer ^^f'l^^^.'^^'^lfZ h^Lptysis with signs of dulness (infarct) over the tight Inng at the asTtd subsequent hemorrhagic effusion, gradually increasing oedenia the extremitls and body, the occurrence of ^-^^-^^'^^^^l^ ^^Z- tion in the amount of urine with allmminuria, enlargement and ten de^ess fthe liver with ascites, further increase of the cardui. dulness. 'r n occasional presystolic murmur at the cardiac apex The m - cal diastolic murmur was constantly present, thougli not so plainly ^^The treatment was directed towards the failing compensation of the he^i' anTeonsisted in digitalis, morphine, strophanthus, calomel, stry- lut'ss encroaclit'tl I' iipo.v wi'i'e de- discovur any ac- tio. Atlhoi?|)ex audildt'. In ad- *tolic in rhythm, inaxiinuin intcu- lur was of rather aid bi' distiiicily host wall, and on ; at a distance of r. The diagnosis ()U9 spi'cuiations, uir just doscribed. s he passed from i. About sixteen •ess had been en- and his sleep was ,i dya[)ncea. The .' hospital differed prominent feature ss and dys|inoea, — g to orthopnoea. on examining the apex was now in cs greater. There The musical dia- 1, yet retaining its the chest wall. A ilage. ^ed on the first of 1 he was finally re- of the same month, hs was marked by 3 tight lung at the y increasing oedema Lorrhoids, a diminu- largement and ten- the cardiac dulness, c apex. The miisi- igh not 80 plainly compensation of the nthus, calomel, stry- nine, potassium iodide, in various combinations and according to in- dications, 'i'lie right pleura whs twic.' aspinK.^I. The (Ftleii,,. wa.s re- lieved by muhipU' puncture of the sldn und.T antis,.|,tic pr.caudons. He died very suddenly on the evening of the 31st of Oclob r. The diagnoHis of this case finally made was a.trtie insullicience. mitral insutHcience with stenosis (?). myocarditis, arteric-sclerosis. seeondarv nephritis, right pulmonary infarct of lower lobe, and hydr..tlio,ax. The autopsy confirmed the diagnosis with but one exception and re- vealed the cause of the anomalous signs. That condition wliieli was always doubtful in this case, viz., mitral stenosis, was not fouiul to be present and the presystolic murmur sometimes heard as (•omp.nsi.ti..n was more completely lost and must evidontlv have been the muimur of Mint associated with aortic regurgitation. But little interest attaches to the autopsy, apart from that which describ;-s the cardiac coudiii -n. Cor bovinum was found, the measurement being 14.25 cm. from side to side. The chambers were greatly enlarged, the right auricular wall? were muscular; the tricuspid orifice admitted four fingeis' tlie right ventricular wall was greatly hypertrophied. The mitral oriliee admitted easily the tips of four fingers. The valve showed no thick- ening, the only abnormal condition about it, apart from the enlarge- ment of the mitral orifice, Ix.ing found in the insertion of one of the chordiB tendinea. arising apparently from a papillary mu.scle and at- tached fully one-half an inch from the aortic cusp upon its ventricular surface and somewhat to the loft of the median line. Springing from the left side of the ventricle another fine tendon was seen to pass to- wards the muscle already described, and to join it just as it passes be- neath the margin of this valve cusp as shown in the photograph, (l-'ig. 1.) Another shorter and somewhat coarser fibrous band united th?9 papillary muscle to the ventrisular surface at a point adjacent to the first. The aortic valve was incompetent, the cusps being greatly thickened and shortened. The anomalous signs in this case give it the interest it posessL's:— (1) It is anomalous to find two diastolic murmurs. Wo had the high- pitched musical murmur and the low-pitched characteristic diastolic murmur of aortic insufficience. (3) It is anomalous to find a diastolic thrill so widely palimbie. Ac- cording to Gibson,— "They are rarely felt except in the precordial re- gion, more especially towards tlie lower part of the sternum and in the neighborhood of the apex." (S) A murmur audible so far from the chest-wall is rarely observed. (4) With equal truth it may be said, further, that a musical diastolic murmur is an anomalous sign. Concerning the cause of this quality of the murmur (4), we thought upon diverse possibilities, and chief among these was a condition of rup- that time Nvhen he «.mta.ned a hoavj an w ^^^^^^^ .^_ barn.w. It is nvuU known that the a.n-t,. ^ !> "^^^"^ ^,,^,,. Ire Willian. reporte.l a oa^e having a musua ^^^^J^'^^^ ,,,,,.,, .as subBcqnently shown to be due to a '^-3';; ^ ^."^ ;, , regur.i- ,f ,,bich "was retroverted in.o th. ^^^^^''^^Z:^,, band w.. t,u,i strean,." Another poss.bdity was > "^ '™^ j^„^,, ,,,,, tl„„ting in the blood .treanu one end att d ^^'^^^ ,,,, fixed. How true thin last possible «-''^'';"" ,^ ^^ ..he t ndine.v shown. It would appear tha. tin. arrangem n ot t u cho _^^^^^ i„ a congenital anonudy. They may luul then P« " "^ ; ^^^, ^,,,.,. tU>n at the edges or upon the ventru-ular sur^.ce ot ^^^ ^,,,, ly i« it ^ound so high up ^^J^StcZ: !^ regugitation the blood stream tlowed " . t'^^ " '" ^ .,f ^lood set those cords took place through the aort.c or. f ice the «t>ea n t ^^^^ tricle and ^^'f"'- /"^--^^^^f ^^^^^^^^^ period of dilatation with rX^X^:":ti.: 1:: !^" and .^th thrill and m.mu. he- ^"■l^irrrr'endiue. though con^— -e ha., bee.; observed by many write., and in Bome -tanees ..^d.a.nos.^ ^^^^^ ^^ presence has been made during ^e. • ^^_^.^ diagnosed \l,dicine, 1S9S, describes five case , tl^ ^J^^^^^,,,, believes, are during me. '^^^^f^^^.;r^lt:tZl pathoh.gical changes, congenital anomalies, whle but a few a J^^^^_. ^^^^^^^1^,, ^hey principally those due fo. atrophy of b.cU yen ^^^^^^ ^^^^^^^^^^ L-e very rarely found in any «the ;Ju mbe .^ ^^^^ p^_^. ^^^.^ ^j ir;::?rrs^x;"i-^ ^^^^ ^'^ ^^^^'^'^ ^"^^ ^"^^^^ ' of this case teaches is that relie of cammc P ^^.derate hyper- tures incident to the disease when t^^^^^^ ^j^^,,^ ^oo, he trophy, are greatly relieved when dUat^tio. ^^^^^^^ i,, ^^s the otlJer features of the case ^^^^"f^^ J^£\TdyBpnoea were present and **" ^ lU)JL10GllA.iniY. Peacock-Transactinn't of ll>e 1 w'^ b , Society, London, pp. !•>•'. V 01. vi B:KS^if=S=s;iJr&s. .™.™a — -*- Me" M regi'igit'dioii il set theso cords y a dilating vt'U- ced, tbe musical : dilatation with and niurniur bo- rare, havo been lagnosis .of their iu the Reiue dn were diagnosetl ilmrd believes, are hological changea, r trabecula'. They heart. Murniura the upper part of thin and posess a •h the observation the agonising fea- moderate hyper- and, tlien, too, the niber, pain was tlie a were presi'nt and came again for ad- Lxth inteispaco and usser in 1897. ;ine, 180.i. ,, , . on, pp. 155 Vol. v.. ,n. pp. !•«., Vol. vi». i, and The Philadelphia i